대 뇌동맥류 및 거대 뇌동맥류의 수술적 가료

임만빈,이창영,김일만,손은익,김동원,Yim, Man-Bin,Lee, Chang-Young,Kim, Ill-Man,Son, Eun-Ik,Kim, Dong-Won 대한신경외과학회 2001 Journal of Korean neurosurgical society Vol.30 No.6

Objectives : The goal of the surgical management of large and giant aneurysm is complete extirpation of the aneurysms with preservation or reconstruction of the parent artery. To improve the surgical management results of those aneurysms in the future, we review our experience and discuss technical maneuvers and strategies used to avoid potential complications of those aneurysm surgery. Material and Methods : During the past 12 years, thirty six cases of large and giant aneurysms(diameter>19mm) were managed by surgery. The clinical characteristics, treatment methods, surgical complications and outcome of those cases were analyzed and, based on the review of the literatures, the preventive methods of surgical complication related to the clipping of those aneurysms were discussed. Results : The locations of those aneurysms were anterior circulation in 34 cases and posterior circulation in 2 cases. The most frequent site of aneurysmal location was a paraclinoidal region of the anterior circulation. The aneurysms were managed surgically by direct clipping of aneurysmal neck in 31 cases, aneurysmal trapping followed by extracranial-intracranial bypass in 2 cases, proximal clipping of parent artery, aneurysmorrhaphy, and excision of aneurysm followed by end to end anastomosis of parent artery in each one case. Surgical complications occurred in 13 cases. A parent vessel occlusion by thrombus formation and parent vessel stenosis after clipping of aneurysm were the main complications. We obtained good outcome in 27, fair 5, poor 1 and dead in 3 case(s). Conclusion : We conclude that selection of suitable management method for each case, high quality of surgical technique and prevention of complication during operation are important key points for the successful treatment of large and giant aneurysm. The heparinization prior to application of temporary clip on parent vessels, aneurysmal decompression during dissection and clipping of aneurysm, complete closing of the aneurysmal neck and avoiding the narrowing of parent vessel after clipping of aneurysm were the main technical maneuvers used to avoid complications of those aneurysm surgery.

뇌동정맥기형의 외과적 수술합병증과 그 처치

임만빈,김일만,Yim, Man-Bin,Kim, Il-Man 대한신경외과학회 2000 Journal of Korean neurosurgical society Vol.29 No.8

Objectives : The goal of surgical management of cerebral arteriovenous malformation(AVM) is elimination of the lesion without development of new neurological deficits. To improve the management results of cerebral AVMs in the future, this article discusses about surgical complications of the AVM and their management. Material and Methods : During the past 18 years, 116 patients with cerebral AVMs were managed by surgery. Among these cases, 7 cases died, 7 cases developed new neurological deficits, 11 cases residual AVM and 5 cases intracerebral hematoma(ICH) after surgery. The author analyzes the causes of those complications and investigates the methods to minimized those complications based on the review of the literatures. Results : One stage removal of AVM and ICH in the poor neurological state were performed in 5 of 7 death cases. Subtotal removal of ICH followed by delayed AVM surgery after recovery is regard as one method to improve the outcome of patient with large ICH. Postoperative new neurological deficits developed owing to normal perfusion pressure breakthrough(NPPB) in 3, judgement error in 2, preoperative embolization in 1 and cortical injury in 1 case(s). Proper management of NPPB, accurate anatomical knowledge and physiological monitoring during operation, and well trained skill for embolization are regard as methods to minimize those complications. Residual AVMs after surgery were noticed in 11 cases, in which unintended 6 cases due to inaccurate dissection of peripheral margin of AVM, and intended 3 cases due to massive brain swelling during operation, 1 cases due to diffuse type and 1 case due to multiple type of AVM. Accurate dissection of peripheral margin of AVM and mild hypotension during operation may help to avoid this complication. Postoperative hemorrhage occurred in 3 cases due to rupture of the residual AVM and in 2 cases due to oozing from the AVM bed. Complete resection of AVM, complete control of bleeding points at AVM bed and mild hypotension during early postoperative period are the methods to avoid this complication. Conclusion : A precise but flexible therapeutic strategy and refined skill for endovascular, radiosurgical and microsurgical techniques are required to successful treatment of cerebral AVM. Adequate timing of AVM resection, accurate anatomical knowledge, proper management of NPPB and accurate dissection of peripheral margin of AVM are the key points for avoiding complications of the AVM surgery.

뇌동맥류의 조기수술 전 재출혈 방지를 위한 항섬유소용해제 투여의 효과

이창영,임만빈,이장철,손은익,김동원,김인홍,Lee, Chang Young,Yim, Man Bin,Lee, Jang Chull,Son, Eun Ik,Kim, Dong Won,Kim, In Hong 대한신경외과학회 2001 Journal of Korean neurosurgical society Vol.30 No.9

파열된 뇌동맥류의 조기수술이 계획된 환자에서 수술전까지 단기간에 걸친 항섬유소용해제 투여의 효과를 알아보기 위해 뇌동맥류성 지주막하출혈 환자 137례에 대하여 60례를 AMCA 투여군으로, 77례를 비 투여군으로 분류하여 재출혈, 증상적 혈관연축, 뇌수두증의 발생빈도 및 전체적인 치료성적을 비교, 분석하였다. 재출혈의 발생빈도는 AMCA 비 투여군에 비해 투여군에서 통계학적으로 유의하게 낮게 나타났고 AMCA의 장기투여에서 증가를 보인 증상적 혈관연축과 뇌수두증의 발생빈도는 양군에서 유의한 차이를 보이지 않았으며 전체적인 치료성적은 AMCA 투여군에서 비 투여군에 비해 보다 양호한 결과를 보였다. 따라서 조기수술이 계획된 뇌동맥류성 지주막하출혈 환자에서 AMCA의 단기간 투여는 재출혈율을 감소시켜 전체적인 치료결과를 향상시키는데 도움이 될 것으로 생각된다. Object : This study was conducted to evaluate whether short-term intravenous infusion of tranexamic acid (AMCA) was able to improve the management outcome by preventing rebleeding without increasing vasospasm and hydrocephalus associated with the long-term administration of this agent in the patients with aneurysmal subarachnoid hemorrhage(SAH) who were planned for the early surgery. Methods : During the period from June, 1996 to May, 1998, 137 patients admitted within 3 days of their SAH and planned for early surgical intervention were subject to study population. Of these, 60 patients who had been treated with AMCA were classified as AMCA treated group and 77 patients without AMCA treatment as AMCA untreated group. Initially, prognostic factors for rebleeding, vasospasm, hydrocephalus and outcome following SAH including age, sex, clinical grade, CT grade, site of ruptured aneurysms, admission day after SAH, surgery day after SAH, number of aneurysms and hypertension history, were analyzed and compared between AMCA treated group and untreated group. Secondly, the incidence of rebleeding, symptomatic vasospasm and hydrocephalus were compared between the two groups. Also, the management outcome of the patients was compared between the two groups. Results : There were no significant differences in prognostic factors between the two groups. The rebleeding rate was 0% in the AMCA treated group whereas the rate was 7.8% in the untreated group. This difference was statistically significant. The incidences of symptomatic vasospasm and hydrocephalus were found not to be significantly different between the two groups. Of the treated group, 31.7% of patients developed hydrocephalus compared to 32.5% of those at the untreated group. Fourteen(23.3%) patients in treated group developed symptomatic vasospasm and 6 of them(10%) suffered stroke whereas incidences of these in untreated group were 25.9% and 11.7%, respectively. The AMCA treated group showed more favorable outcome than that of untreated group. There was no case of death by rebleeding in the AMCA treated group while one of the main causes of death in the untreated group was rebleeding. Conclusion : Short-term high-dose AMCA administration is considered beneficial in improving outcome and diminishing the risk of rebleeding in the patients who suffer from an aneurysmal SAH prior to early surgical intervention.

가성동맥류의 수술적 가료

김재홍,임만빈,이창영,김일만,Kim, Jae Hong,Yim, Man Bin,Lee, Chang Young,Kim, Ill Man 대한신경외과학회 2001 Journal of Korean neurosurgical society Vol.30 No.3

Objective : Surgical experiences of pseudoaneurysms such as traumatic, mycotic and ill-defined unknown causes of aneurysms are rare. The authors have studied the results of surgical management from such cases in our series. Patients and Method : In the last 17 years, 1320 patients with cerebrovascular aneurysms were managed surgically. Among these, 16 patients showed the pseudoaneurysms. The authors analyzed retrospectively the clinical characteristics, treatment methods, management outcomes and problems in the managements. Results : There were 6 patients with traumatic aneurysm, 4 mycotic aneurysms and 6 ill-defined unknown causes of aneurysm. The sites of traumatic aneurysms were cavernous portion of the internal carotid artery(n=3), distal portion of the anterior cerebral artery (n=2) and vertebral artery(VA : n=1). Good outcomes in 5 cases could be obtained by extracranial - intracranial bypass followed by parent vessel occlusion or resection of aneurysm followed by re-anastomosis of parent vessel. The sites of mycotic aneurysm were peripheral portions of middle cerebral artery(MCA : n=3) and posterior cerebral artery(PCA : n=1). The outcomes of the patients with a mycotic aneurysm were relatively poor. It was partially due to the development of new aneurysm after treatment in one. The sites of ill-defined unknown causes of aneurysm were extracranial carotid artery(n=3), V2 portion of the VA(n=1), peripheral portion of the PCA (n=1) and MCA(n=1). Good outcome in all cases could be obtained by resection of aneurysm with or without saphenous vein graft. Conclusion : For the treatments of cerebrovascular pseudoaneurysm, combinations of aggressive medical, endovascular and surgical managements seem mandatory. Insertion of stent for a extracranial carotid artery aneurysm and coiling for a peripheral mycotic aneurysm can be option in future.

뇌동맥류에서 혈관형성 인자와 혈관벽 기질 단백에 대한 면역조직화학적 연구

김재홍,임만빈,이창영,김상표,Kim, Jae Hong,Yim, Man Bin,Lee, Chang Young,Kim, Sang Pyo 대한신경외과학회 2000 Journal of Korean neurosurgical society Vol.29 No.12

Objective : Until now, it has been little known about the biological mechanisms associated with the genesis, growth, and rupture of intracranial aneurysm. This study was performed to investigate and understand a part of these mechanisms. Materials and Methods : Immunohistochemical stains for angiogenesis growth factors(basic fibroblast growth factor (bFGF) and vascular endothelial growth factor(VEGF)) and selected vascular wall matrix proteins(alpha smooth muscle actin(${\alpha}SMA$) and collagen Type IV) were performed in fixed sections from a normal circle of Willis artery which was taken from the autopsy specimen as a control vessel and 17 aneurysmal wall specimens which was taken during surgical clipping of aneurysms. The staining intensity and distribution of immunoreactivity to angiogenesis growth factors and selected wall matrix proteins in control vessel and aneurysmal wall were examined and compared with each other. The difference of staining intensity according to the size of aneurysm was also investigated. Results : There was no immunoreactivity to bFGF and VEGF in the control vessel. bFGF immunoreactivity was exhibited in 15 of 17 aneurysm specimens around smooth muscle cells within the media of aneurysm. VEGF immunoreactivity was also exhibited in all aneurysm specimens in patches or diffusely affecting all layers of the aneurysmal wall. The degrees of intensity of bFGF and VEGF immunoexpression were proportionate roughly to the size of aneurysm. Strong immunoexpression of both factors were noticed in large aneurysm. A regularly arranged and defined band of immunoreactivity of ${\alpha}SMA$ was noticed in the media of the control vessel, whereas diffuse, faint, irregularly arranged ${\alpha}SMA$ was noticed in the aneurysmal wall. A regularly defined band of collagen Type IV immunoreactivity was also noticed in the subendothelium of the control vessel, whereas diffuse disorganized immunoreactivity of collagen Type IV was noticed in the entire wall of the aneurysm. Conclusion : These results indicate substantial evidences of abnormal expression of angiogenesis factors and changes of selected vascular wall matrix proteins in the wall of intracranial aneurysm. The unbalanced changes of angiogenesis factors and vascular wall matrix proteins in the wall of aneurysm may be one of the biological mechanisms for the growth and rupture of aneurysm.

원발성 뇌하수체 농양 - 2례 보고 -

이성열,이창영,임만빈,Lee, Sung Yeal,Lee, Chang Young,Yim, Man Bin 대한신경외과학회 2000 Journal of Korean neurosurgical society Vol.29 No.8

Pituitary abscess is a very rare disorder, since antibiotics therapy has become widely available. Clinically and radiologically, the preoperative diagnosis of pituitary abscess is difficult because of its features which may be identical to those of any space-occupying lesions of the sella turcica. A combination of clinical features, such as meningitis, paranasal sinusitis and panhypopituitarism with intrasellar cystic lesion with homogeneous ring enhancement on computed tomography or magnetic resonance image should raise the suspicion of a pituitary abscess. Drainage of the abscess through trans-sphenoidal approach, appropriate antibiotics therapy, endocrine assessment and hormonal replacement should bring complete recovery to the patient. The authors review the literature and report two cases of primary pituitary abscess.

뇌종양 제거 후 원격부위에 발생한 뇌경막외혈종 - 증례보고 -

배광주,김일만,임만빈,Bae, Kwang-Ju,Kim, Ill-Man,Yim, Man-Bin 대한신경외과학회 2001 Journal of Korean neurosurgical society Vol.30 No.3

Objective : The authors present three cases of brain tumors in which epidural hematomas(EDHs) were developed postoperatively in the remote areas from craniotomy sites. The preventive tactics as well as possible mechanisms of development of remote EDH are discussed. Material and Methods : The magnetic resonance imagings of three patients revealed a left lateral ventricular mass located just aside of foramen Monro in a 27-year-old male, a large cystic mass in the temporal lobe in a 35-year-old male, and a partially calcified pineal mass in a 27-year-old male patient. The surgical removals of these tumors were performed without any noticeable events during surgery via left frontal transcortical transventricular approach for lateral ventricular tumor, left temporal craniotomy for cystic temporal tumor, and right occipital transtentorial approach for pineal tumor. Results : Postoperative EDHs remote from the sites of craniotomy were detected by the immediate postoperative computerized tomographic scans. We obtained good outcomes without any morbidity in all three patients with emergent evacuation of the hematoma. The pathologic diagnoses were lateral ventricular ependymoastrocytoma, temporal craniopharyngioma and mixed germinoma of the pineal region. Conclusion : It is postulated that a sudden reduction of intracranial pressure(ICP) at the time of tumor removal may strip the dura from the inner table of the skull to cause EDH from the remote site of craniotomy. Gradual reduction of ICP with slow drainage of cerebrospinal fluid before tumor removal as well as lowering the head position of patient during surgery might be helpful for preventing this unusual complication.

자발성 뇌내혈종의 음압배액술

김일만,손은익,김동원,임만빈,Kim, Il-Man,Son, Eun Ik,Kim, Dong Won,Yim, Man Bin 대한신경외과학회 2000 Journal of Korean neurosurgical society Vol.29 No.6

Objectives : The less invasive stereotactic surgery of hypertensive intracerebral hematoma has been preferred. Many techniques were developed to facilitate aspiration of a dense blood clot in acute stage. Authors describe a method for evacuation of putaminal hematoma via computerized tomography(CT)-aided free-hand stereotactic infusion of urokinase and frequent negative pressure aspiration. Patients and Methods : A total of ten patients with spontaneous putaminal hematoma underwent surgery with negative pressure aspiration in the three-year period. All procedures were performed within 12 hours of insult. A silicone ventricular catheter was inserted into the center of hematoma through a burr hole at the Kocher's point under local anesthesia. In a typical case of putaminal hematoma, the trajectory of catheter was pointed the center of hematoma parallel to sagittal plane vertically and the external auditory meatus posteriorly. Immediately after the first trial of hematoma aspiration low-dose urokinase solution(2,000IU/5ml saline) was administrated through the catheter and drain was clipped for 30 minutes. Subsequently, the partially liquified hematoma was manually aspirated using a 10ml syringe with a negative pressure of less than 2 to 3ml. The procedure was carefully repeated every 1 hour until the hematoma was near totally evacuated. Results : The patients population consisted composed of 4 men and 6 women with a mean age of 61.6 years. All had major neurological deficits preoperatively. The mean hematoma volume was 44.3 ml and hematoma was drained for 20 to 48 hours. No complications such as rebleeding, meningitis, or malplaced catheter were noted. Outcome was moderately disabled in four patients and good recovery in three patients. Conclusion : Although the frequent negative pressure aspiration and low-dose urokinase infusion has the disadvantage of possbility of rebleeding and infection, it is consisdered to be an effective method because it allows a simple, safe, and complete removal of hematoma.

원발성 중추신경계 림프종의 치료전략

김일만,이창영,손은익,김동원,임만빈,김상표,Kim, Il-Man,Lee, Chang Young,Son, Eun Ik,Kim, Dong Won,Yim, Man Bin,Kim, Sang Pyo 대한신경외과학회 2001 Journal of Korean neurosurgical society Vol.30 No.3

Objective : We have currently changed treatment strategies to methotrexate(MTX)-based preirradiation chemotherapy with subsequent planned radiation for the initial therapy of primary central nervous system lymphoma (PCNSL). The aim of this study was to evaluate the results of treating PCNSL with chemotherapy plus radiotherapy (CRT) or radiotherapy(RT) alone. Method and Material : This study involved 10 females and 3 males patients with a mean age of 54.2 years. All patients underwent surgery, open(8 cases) or stereotactic biopsy(5 cases) for histological diagnosis. Eleven tumors were diffuse large B-cell lymphomas. Tumor volume change in the follow-up images and survival time were evaluated in patients treated with CRT and RT alone. In the beginning, two patients received ProMACE-Cytabom chemotherapeutic regimen, but did not complete the course and died of progressive tumor 8 and 9 months after diagnosis, respectively. One patient died at 6 months before chemotherapy. These three were excluded from the survival analysis. Five patients(RT group) completed full courses of cranial irradiation with or without boost. For the current combined modality treatment, high-dose MTXbased chemotherapy(systemic and intrathecal MTX, IV vincristine, and oral procarbazine) followed by whole brain irrdiation to 45Gy to tumor was introduced in 5 patients of CRT group. Result : A complete response was achieved in three of five who received RT only and in all of five who received CRT. All patients in CRT groups are in disease free status at a mean 23 months following therapy. The RT group patients refused any additional salvage therapy at tumor relapse and survived at mean 20 months from diagnosis. The Karnofsky performance status improved in eight of ten patients with treatment. The treatment toxicity included leukoencephalopathy in RT group and severe leukopenia, transient hepatitis, avascular necrosis of femoral head, hearing loss, and amenorrhea in CRT group, respectively. Conclusion : The combined modality therapy of MTX-based chemotherapy plus radiotherapy for PCNSL may enhance tumor response and improve patient survival. The patients who received CRT should be carefully followed up because of the higher risk of treatment-induced late neurotoxicity.

일차 배양 해마신경세포에서 NMDA- 및 Glutamate- 유도전류의 특성

김일만,손은익,김동원,김인홍,임만빈,송대규,박원균,배재훈,최하영,Kim, Il-Man,Son, Eun-Ik,Kim, Dong-Won,Kim, In-Hong,Yim, Man-Bin,Song, Dae-Kyu,Park, Won-Kyun,Bae, Jae-Hun,Choi, Ha-Young 대한신경외과학회 2000 Journal of Korean neurosurgical society Vol.29 No.11

Objectives : This study was performed in cultured rat hippocampal neurons to investigate the acute electrophysiological features of ionotropic glutamate receptors which act as a major excitatory neurotransmitter in mammalian brain. Method : Glutamate receptor agonists were applied into the bath solution embedding in whole-cell patch-clamp recording of single hippocampal neuron. Results : In voltage-clamped at -60mV and the presence of 1mmol $Mg^{2+}$, extracellulary applied NMDA did not induce any inward current. Both the elimination of $Mg^{2+}$ and addition of glycine in bath, however, elicited a NMDAinduced inward current. $Mg^{2+}$ block current was increased gradually in more negative potentials from -30mV, showing a negative slope in I-V plot with $Mg^{2+}$. Glutamate-induced current represented an outward rectification. A non-NMDA receptor component occupied about 40% of glutamate-induced current in the voltage range of -80mV to +60mV. Conclusion : Present study suggests that glutamate activates acutely the non-NMDA receptors which induces an inward current in the level of resting membrane potential. This makes the membrane potential increase and can activate the NMDA receptors that permit calcium influx against $Mg^{2+}$ block. At the depolarized state of neuron, there may be recovery mechanisms of membrane potential to repolarize irrespective of voltage-dependent potassium channels in the hippocampal neurons.